Contemporary Nodal Management and Overall Survival of Older Patients with HR-/HER2+ Breast Cancer

Contemporary guidelines recommend omission of surgical nodal staging for patients age 70 years or older with early-stage cN0 HR+/HER2- breast cancer (BC) but exclude those with HER2+BC. This study aimed to investigate surgical nodal management of patients age 70 years or older with HR-/HER2+BC, analyze overall survival (OS) by nodal surgery type, and identify factors associated with surgical nodal omission.

The study enrolled women age 70 years or older with stages I to III HR-/HER2+BC in the National Cancer Database (NCDB) who underwent upfront surgery from 2017 to 2019. Nodal management was defined by the number of nodes examined as follows: omission (0 nodes), SLNB (1-5 nodes), and ALND (>10 nodes). Multinomial logistic regression and Kaplan-Meier analysis were performed.

Of 1853 patients, 42.8 % were age 70 to 75 years, and 74.5 % had a Charlson Comorbidity Index (CCI) of 0. Most (90 %) had stage I or II disease and had undergone lumpectomy (57.2 %). Overall, 10.5 % had omission of nodal surgery, whereas 68.1 % had SLNB and 9.8 % had ALND. The 3-year OS was worse for the patients with omission (58 %) than for those with SLNB (88 %) or ALND (69 %) (p < 0.01). The factors associated with omission were age older than 81 years (odds ratio [OR], 4.4; 95 % confidence interval [CI], 2.7-6.9) and stage III disease (OR, 2.2; 95 % CI 1.1-4.9). The patients with nodal omission were twice as likely to die as those with SLNB (hazard ratio, 2.0; 95 % CI 1.5-2.7).

In this cohort, 10.5 % of the patients with HR-/HER2+BC had omission of nodal surgery, including some patients with locally advanced and cN+ disease. Nodal omission was associated with inferior OS. Nodal staging should remain the standard of care for this population, except for those whose management or survival would not be altered by it.